Position of the Academy of Nutrition and Dietetics: Medical Nutrition Therapy Behavioral Interventions Provided by Dietitians for Adults With Overweight or Obesity, 2024.

Providing interventions that facilitate improvement of dietary intake and other health behaviors can improve nutrition-related outcomes in adults with overweight or obesity. Medical nutrition therapy (MNT) behavioral interventions require expertise from registered dietitian nutritionists or international equivalents (dietitians), which no other health care provider can provide for adults with obesity. Current evidence supports the role of MNT behavioral interventions for adults with overweight or obesity as an effective treatment option, when appropriate for and desired by the client. This Academy of Nutrition and Dietetics Position Paper describes potential benefits and concerns regarding dietitian-provided MNT behavioral interventions for adults with overweight and obesity and informs dietitians about implications for practice. This Position Paper is supported by a systematic review examining effectiveness of MNT interventions provided by dietitians and by an evidence-based practice guideline. It is the position of the Academy of Nutrition and Dietetics that MNT behavioral interventions for adults (aged 18 years and older) with overweight or obesity should be a treatment option, when appropriate and desired by the client, to improve cardiometabolic, quality of life, and anthropometric outcomes. Dietitians providing MNT recognize the complex contributors to overweight and obesity, and thus individualize interventions, based on a shared decision-making process, and deliver interventions in an inclusive, compassionate, and client-centered manner. Interventions should include collaboration with an interprofessional team when needed. Dietitians strive to increase health equity and reduce health disparities by advocating and providing opportunities for increased access to effective nutrition care services. This position remains in effect until December 31, 2031.

Weight Management Interventions Provided by a Dietitian for Adults with Overweight or Obesity: An Evidence Analysis Center Systematic Review and Meta-Analysis.

BACKGROUND: Obesity is associated with a multitude of comorbidities and considerable health care costs. OBJECTIVE: The objective of this review was to examine the efficacy of weight management interventions provided by a registered dietitian or international equivalent (referred to as "dietitian"). METHODS: This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the effect of weight management interventions provided by a dietitian, compared with usual care or no intervention, on several cardiometabolic outcomes and quality of life in adults with overweight or obesity. MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for eligible RCTs published between January 2008 and January 2021 in the English language. Meta-analyses were conducted using a random-effects model, publication bias was assessed using funnel plots and Egger's statistics, and heterogeneity was assessed by interpreting I2 values. Efficacy of intervention components, such as telehealth or group contacts, were explored in sub-group analyses. Version 2 of the risk-of-bias tool for RCTs was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation method was used to determine certainty of evidence. RESULTS: This systematic review included 62 RCTs. Compared with control conditions, weight management interventions provided by a dietitian resulted in improved body mass index (mean difference [MD] -1.5; 95% CI -1.74 to -1.26; moderate evidence certainty); percent weight loss (MD -4.01%; 95% CI -5.26% to -2.75%; high evidence certainty); waist circumference (MD -3.45 cm; 95% CI -4.39 to -2.51 cm; high evidence certainty); blood pressure (MD -3.04 mm Hg; 95% CI -5.10 to -0.98 mm Hg and MD -1.99 mm Hg; 95% CI -3.02 to -0.96 mm Hg for systolic blood pressure and diastolic blood pressure, respectively; moderate and low evidence certainty); and quality of life using the 36-Item Short Form Survey (MD 5.84; 95% CI 2.27 to 9.41 and 2.39; 95% CI 1.55 to 3.23 for physical and mental quality of life, respectively; low and moderate evidence certainty). CONCLUSIONS: For adults with overweight or obesity, weight management interventions provided by a dietitian are efficacious for improving several examined cardiometabolic outcomes and quality of life.

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline.

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.

Misclassification of fourth-grade children's participation in school-provided meals based on parental responses relative to administrative daily records.

Although many studies have relied on parental responses concerning children's school-meal participation, few studies have evaluated parental response accuracy. We investigated misclassification of fourth-grade children's participation in school-meal programs based on parental responses relative to administrative daily records using cross-sectional study data collected for 3 school years (2004-05, 2005-06, and 2006-07) for 1,100 fourth-grade children (87% black; 52% girls) from 18 schools total in one district. Parents reported children's usual school-meal participation on paper consent forms. The district provided administrative daily records of individual children's school-meal participation. Researchers measured children's weight and height. "Usual participation" in breakfast/lunch was defined as ≥50% of days. Parental responses misclassified 16.3%, 12.8%, 19.8%, and 4.7% of children for participation in breakfast, classroom breakfast, cafeteria breakfast, and lunch, respectively. Parental responses misclassified more children for participation in cafeteria than classroom breakfast (P=0.0008); usual-participant misclassification probabilities were less than nonusual-participant misclassification probabilities for classroom breakfast, cafeteria breakfast, and lunch (P<0.0001 for each) (two-proportion z tests). Parental responses concerning children's participation were more accurate for lunch than breakfast; parents overstated breakfast participation (both classroom and cafeteria) and lunch participation. Breakfast participation misclassification was not related to body mass index (P=0.41), sex (P=0.40), age (P=0.63), or socioeconomic status (P=0.21) (multicategory logistic regression controlling for school year, breakfast location, and school). Relying on parental responses concerning children's school-meal participation may hamper researchers' abilities to detect relationships that have policy implications for the child nutrition community. The use of administrative daily records of children's school-meal participation is recommended.

Examining variations in fourth-grade children's participation in school-breakfast and school-lunch programs by student and program demographics.

PURPOSE/OBJECTIVES: Analyses were conducted to examine variations in fourth-grade children's participation in school-breakfast and school-lunch programs by weekday, month, socioeconomic status, absenteeism, sex, and school-breakfast location. METHODS: Fourth-grade children were participants in a dietary-reporting validation study during the 2005-2006 or 2006-2007 school years in 17 or 8 schools, respectively, in one South Carolina school district. For the two respective school years, school-breakfast location was the classroom for six and seven schools, and for the remaining schools, the cafeteria. District administrative records provided information about 180 possible days of participation in the school-breakfast and school-lunch programs for each of 1,060 children (91% Black, 52% girls). The state's Office of Research and Statistics linked data on school-meal participation with information about individual children's socioeconomic status (eligibility for free or reduced-price school meals) and annual absenteeism from school. RESULTS: For school-provided breakfast, logistic regression showed participation rate differences by weekday (smallest for Monday [56.1%], largest for Wednesday [57.8%], p<0.0001), month (smallest for April [53.5%], largest for September [60.8%], p<0.0001), socioeconomic status (smallest for full-price status [27.5%], largest for free-meal status [63.4%], p<0.0001), school-breakfast location (smaller for breakfast located in the cafeteria [38%] than classroom [71%], p<0.0001), and absenteeism (p<0.0001). For school-provided lunch, logistic regression showed participation rate differences by weekday (smallest for Friday [81.9%], largest for Thursday [83.3%], p<0.0001), month (smallest for May [78.7%], largest for August [86.0%], p<0.0001), socioeconomic status (smallest for full-price status [72.1%], largest for free-meal status [84.9%], p<0.0001), and absenteeism (p<0.0001). There were no differences in participation rate by sex. APPLICATIONS FOR CHILD NUTRITION PROFESSIONALS: Administrative participation records are used for forecasting purchasing and production. Using such records in research studies may provide insight into aspects of children's participation in school-provided meals. Districts and managers are encouraged to share administrative records of children's participation in school-provided meals with researchers.

A qualitative study of interviewer-administered physical activity recalls by children.

BACKGROUND: Qualitative methods were used to better understand how to obtain interviewer-administered recalls of physical activity from children. METHODS: Subjects were 24 third- and fifth-grade children from 1 school in Columbia, South Carolina. Cognitive interviews targeted different retention intervals (about the same or previous school day). Round 1's protocols used an open format and had 4 phases (obtain free recall, review free recall, obtain details, review details). Round 2's protocols used a chronological format and had 3 phases (obtain free recall, obtain details, review details). Trained coders identified discrepancies across interview phases in children's recalls of physical activity at physical education (PE) and recess. Based on the school's schedule, children's reports of PE and recess were classified as omissions (scheduled but unreported) or intrusions (unscheduled but reported). RESULTS: Across interview phases, there were numerous discrepancies for Round 1 (regardless of grade, sex, or retention interval) but few discrepancies for Round 2. For Rounds 1 and 2, respectively, 0% and 0% of children omitted PE, while 33% and 0% intruded PE; 44% and 56% of children omitted recess, while 33% and 0% intruded recess. CONCLUSIONS: Results provide important information for facilitating interviewer-administered recalls of physical activity with elementary-age children.

Secondary analyses of data from 4 studies with fourth-grade children show that sex, race, amounts eaten of standardized portions, and energy content given in trades explain the positive relationship between body mass index and energy intake at school-provided meals.

Results from a 2012 article showed a positive relationship between children's body mass index (BMI) and energy intake at school-provided meals. To help explain that positive relationship, secondary analyses investigated (1) whether the relationship differed by sex and race and (2) the relationship between BMI and 6 aspects of school-provided meals--amounts eaten of standardized portions, energy content given in trades, energy intake received in trades, energy intake from flavored milk, energy intake from a la carte ice cream, and breakfast type. Data were from 4 studies conducted 1 per school year (1999-2000 to 2002-2003). Fourth-grade children (n = 328; 50% female; 54% black) from 13 schools total were observed eating school-provided breakfast and lunch on 1 to 3 days per child for 1178 total meals (50% breakfast). Children were weighed and measured. Marginal regression models were fit using BMI as the dependent variable. For purpose 1, independent variables were energy intake at school-provided meals, sex, race, age, and study; additional models included interaction terms involving energy intake and sex/race. For purpose 2, independent variables were the 6 aspects of school-provided meals, sex, race, age, and study. The relationship between BMI and energy intake at school-provided meals differed by sex (P < .0001; stronger for females) and race (P = .0063; stronger for black children). BMI was positively related to amounts eaten of standardized portions (P < .0001) and negatively related to energy content given in trades (P = .0052). Explaining the positive relationship between BMI and energy intake at school-provided meals may contribute to school-based obesity prevention efforts.

Nonsignificant relationship between participation in school-provided meals and body mass index during the fourth-grade school year.

Data from four cross-sectional studies involving fourth-grade children were analyzed to investigate the relationship between participation in school-provided meals and body mass index (BMI), and the effect observed energy intake has on that relationship. Participation and BMI data were available on 1,535 children (51% black; 51% girls) for 4 school years (fall 1999 to spring 2003; one study per school year) at 13 schools total. Direct meal observations were available for a subset of 342 children (54% black; 50% girls) for one to three breakfasts and one to three lunches per child for a total of 1,264 school meals (50% breakfast). Participation in breakfast, lunch, and combined (both meals on the same day) was determined from nametag records compiled for meal observations for each study. Weight and height were measured. A marginal regression model was fit with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, combined participation, sex, age, race, and study. For the subset of children, observed energy intake at breakfast, lunch, and combined was included in additional analyses. Participation in breakfast, lunch, and combined was not significantly associated with BMI regardless of whether analyses included observed energy intake (P values >0.181). The relationship between observed energy intake at breakfast and lunch, separately and combined, with BMI was positive (P values <0.01). In conclusion, these results do not support a relationship between school-meal participation and BMI but do support a relationship between observed energy intake at school meals and BMI during fourth grade.

How accurate are parental responses concerning their fourth-grade children's school-meal participation, and what is the relationship between children's body mass index and school-meal participation based on parental responses?

BACKGROUND: This article investigated (1) parental response accuracy of fourth-grade children's school-meal participation and whether accuracy differed by children's body mass index (BMI), sex, and race, and (2) the relationship between BMI and school-meal participation (based on parental responses). METHODS: Data were from four cross-sectional studies conducted from fall 1999 to spring 2003 with fourth-grade children from 13 schools total. Consent forms asked parents to report children's usual school-meal participation. As two studies' consent forms did not ask about lunch participation, complete data were available for breakfast on 1,496 children (51% Black; 49% boys) and for lunch on 785 children (46% Black; 48% boys). Researchers compiled nametag records (during meal observations) of meal participation on randomly selected days during children's fourth-grade school year for breakfast (average nametag days across studies: 7-35) and for lunch (average nametag days across studies: 4-10) and categorized participation as "usually" (≥ 50% of days) or "not usually" (< 50% of days). Weight and height were measured. Concerning parental response accuracy, marginal regression was used with agreement between parental responses and nametag records as the dependent variable; independent variables were BMI, age, sex, race, and study. Concerning a relationship between BMI and school-meal participation, marginal regression was used with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, age, sex, race, and study. RESULTS: Concerning breakfast participation and lunch participation, 74% and 92% of parents provided accurate responses, respectively. Parental response accuracy was better for older children for breakfast and lunch participation, and for Black than White children for lunch participation. Usual school-meal participation was significantly related to children's BMI but in opposite directions -- positively for breakfast and inversely for lunch. CONCLUSIONS: Parental response accuracy of children's school-meal participation was moderately high; however, disparate effects for children's age and race warrant caution when relying on parental responses. The BMI results, which showed a relationship between school-meal participation (based on parental responses) and childhood obesity, conflict with results from a recent article that used data from the same four studies and found no significant relationship when participation was based on nametag records compiled for meal observations.

Development of the behaviorally focused fruits & Veggies--More Matters public health initiative.

Due to changing recommendations for fruit and vegetable (F/V) intake, public health and private organizations recognized the need to revise communications and programs that promote F/V consumption. This article describes formative research conducted in 2005 to develop a new identity for the 5 A Day Program, updated to the Fruits & Veggies--More Matters program. The objective was to re-brand the 5 A Day Program's campaign message to be adaptable, sustainable, and compelling, while leveraging the program's existing message dissemination infrastructure. Formative research included interviews with representatives from government, nonprofit organizations, and industry, and consumer perspectives from interviews, focus groups, and an online survey. Public health and private organizations agreed that a compelling emotional benefit was needed to motivate consumers to eat more F/V and that messaging needed to be used consistently among national, state, and local programs. Interviews and focus groups targeted mothers who believed they and their families were getting enough F/V, knew they could eat more, but needed to be convinced why they should do so. The most effective messages appealed to mothers' emotional needs to be responsible, leveraged functional intrinsic values of F/V, did not try to quantify "enough," and focused on small steps. When the Fruits & Veggies-More Matters slogan and graphic were viewed together, the majority (62%) said it increased their interest in eating more F/V. The Fruits & Veggies-More Matters brand offers numerous opportunities for promoting F/V consumption through this public health initiative.

Validation of the school lunch recall questionnaire to capture school lunch intake of third- to fifth-grade students.

Children's dietary intake is a key variable in evaluations of school-based interventions. Current methods for assessing children's intake, such as 24-hour recalls and meal observations, are time- and resource-intensive. As part of a study to evaluate the impact of farm-to-school programs, the school lunch recall was developed from a need for a valid and efficient tool to assess school lunch intake among large samples of children. A self-administered paper-and-pencil questionnaire, the school lunch recall prompts for school lunch items by asking children whether they chose a menu item, how much of it they ate, how much they liked it, and whether they would choose it again. The school lunch recall was validated during summer school in 2008 with 18 third- to fifth-grade students (8 to 11 years old) in a North Carolina elementary school. For 4 consecutive days, trained observers recorded foods and amounts students ate during school lunch. Students completed the school lunch recall immediately after lunch. Thirty-seven total observation school lunch recall sets were analyzed. Comparison of school lunch recalls against observations indicated high accuracy, with means of 6% for omission rate (items observed but unreported), 10% for intrusion rate (items unobserved but reported), and 0.63 servings for total inaccuracy (a measure that combines errors for reporting items and amounts). For amounts, accuracy was high for matches (0.06 and 0.01 servings for absolute and arithmetic differences, respectively) but lower for omissions (0.47 servings) and intrusions (0.54 servings). In this pilot study, the school lunch recall was a valid, efficient tool for assessing school lunch intake for a small sample of third- to fifth-grade students.

Relation of Children's Dietary reporting accuracy to cognitive ability.

A validation study of children's dietary reporting provided an opportunity to investigate whether cognitive ability is a source of systematic error in dietary recalls. From the fall of 2004 through the spring of 2007, fourth-grade children (n = 374) in Columbia, South Carolina, were observed eating school meals and interviewed to obtain 24-hour dietary recalls; subsequently, measures of dietary reporting error were calculated. The common factor extracted from 4 subject-area achievement tests (scores on which were provided by the school district for 362 children) was used as a measure of cognitive ability. For the 325 children who reported school meals that met the criteria to be reports about school meals, as cognitive ability increased, dietary reporting error decreased; the relation between cognitive ability and dietary reporting performance was stronger among girls than among boys. The mean cognitive ability for 37 children who reported no meals that satisfied the criteria for being reports about school meals was significantly lower than that for the 325 children who reported meals that satisfied these criteria. These findings indicate that cognitive ability is a source of systematic error in children's dietary recalls. More generally, the quality of epidemiologic survey data may depend systematically on the cognitive ability of respondents.

Shortening the retention interval of 24-hour dietary recalls increases fourth-grade children's accuracy for reporting energy and macronutrient intake at school meals.

BACKGROUND: Accurate information about children's intake is crucial for national nutrition policy and for research and clinical activities. To analyze accuracy for reporting energy and nutrients, most validation studies utilize the "conventional approach," which was not designed to capture errors of reported foods and amounts. The "reporting-error-sensitive approach" captures errors of reported foods and amounts. OBJECTIVE: To extend results to energy and macronutrients for a validation study concerning retention interval (elapsed time between to-be-reported meals and the interview) and accuracy for reporting school-meal intake, the conventional and reporting-error-sensitive approaches were compared. DESIGN AND PARTICIPANTS/SETTING: Fourth-grade children (n=374) were observed eating two school meals, and interviewed to obtain a 24-hour recall using one of six interview conditions from crossing two target periods (prior 24 hours and previous day) with three interview times (morning, afternoon, and evening). Data were collected in one district during three school years (2004-2005, 2005-2006, and 2006-2007). MAIN OUTCOME MEASURES: Report rates (reported/observed), correspondence rates (correctly reported/observed), and inflation ratios (intruded/observed) were calculated for energy and macronutrients. STATISTICAL ANALYSES PERFORMED: For each outcome measure, mixed-model analysis of variance was conducted with target period, interview time, their interaction, and sex in the model; results were adjusted for school year and interviewer. RESULTS: With the conventional approach, report rates for energy and macronutrients did not differ by target period, interview time, their interaction, or sex. With the reporting-error-sensitive approach, correspondence rates for energy and macronutrients differed by target period (four P values <0.0001) and the target period by interview-time interaction (four P values <0.0001); inflation ratios for energy and macronutrients differed by target period (four P values <0.0001), and inflation ratios for energy and carbohydrate differed by the target period by interview-time interaction (both P values <0.005). CONCLUSIONS: Shortening the retention interval of dietary recalls increases accuracy for reporting energy and macronutrients. For validation studies, it is best to obtain reference information from a method that provides details about foods and amounts consumed and to use an analytic approach that captures errors of reported foods and amounts.

Children's body mass index, participation in school meals, and observed energy intake at school meals.

BACKGROUND: Data from a dietary-reporting validation study with fourth-grade children were analyzed to investigate a possible relationship of body mass index (BMI) with daily participation in school meals and observed energy intake at school meals, and whether the relationships differed by breakfast location (classroom; cafeteria). METHODS: Data were collected in 17, 17, and 8 schools during three school years. For the three years, six, six, and seven of the schools had breakfast in the classroom; all other schools had breakfast in the cafeteria. Information about 180 days of school breakfast and school lunch participation during fourth grade for each of 1,571 children (90% Black; 53% girls) was available in electronic administrative records from the school district. Children were weighed and measured, and BMI was calculated. Each of a subset of 465 children (95% Black; 49% girls) was observed eating school breakfast and school lunch on the same day. Mixed-effects regression was conducted with BMI as the dependent variable and school as the random effect; independent variables were breakfast participation, lunch participation, combined participation (breakfast and lunch on the same day), average observed energy intake for breakfast, average observed energy intake for lunch, sex, age, breakfast location, and school year. Analyses were repeated for BMI category (underweight/healthy weight; overweight; obese; severely obese) using pooled ordered logistic regression models that excluded sex and age. RESULTS: Breakfast participation, lunch participation, and combined participation were not significantly associated with BMI or BMI category irrespective of whether the model included observed energy intake at school meals. Observed energy intake at school meals was significantly and positively associated with BMI and BMI category. For the total sample and subset, breakfast location was significantly associated with BMI; average BMI was larger for children with breakfast in the classroom than in the cafeteria. Significantly more kilocalories were observed eaten at breakfast in the classroom than in the cafeteria. CONCLUSIONS: For fourth-grade children, results provide evidence of a positive relationship between BMI and observed energy intake at school meals, and between BMI and school breakfast in the classroom; however, BMI and participation in school meals were not significantly associated.

Fourth-grade children's dietary recall accuracy is influenced by retention interval (target period and interview time).

BACKGROUND: For a 24-hour dietary recall, two possible target periods are the prior 24 hours (24 hours immediately preceding the interview time) and previous day (midnight to midnight of the day before the interview), and three possible interview times are morning, afternoon, and evening. Target period and interview time determine the retention interval (elapsed time between to-be-reported meals and the interview), which, along with intervening meals, can influence reporting accuracy. OBJECTIVE: The effects of target period and interview time on children's accuracy for reporting school meals during 24-hour dietary recalls were investigated. DESIGN AND SUBJECTS/SETTING: During the 2004-2005, 2005-2006, and 2006-2007 school years in Columbia, SC, each of 374 randomly selected fourth-grade children (96% African American) was observed eating two consecutive school meals (breakfast and lunch) and interviewed to obtain a 24-hour dietary recall using one of six conditions defined by crossing two target periods with three interview times. Each condition had 62 or 64 children (half boys). MAIN OUTCOME MEASURES: Accuracy for reporting school meals was quantified by calculating rates for omissions (food items observed eaten but unreported) and intrusions (food items reported eaten but unobserved); a measure of total inaccuracy combined errors for reporting food items and amounts. STATISTICAL ANALYSES PERFORMED: For each accuracy measure, analysis of variance was conducted with target period, interview time, their interaction, sex, interviewer, and school year in the model. RESULTS: There was a target-period effect and a target-period by interview-time interaction on omission rates, intrusion rates, and total inaccuracy (six P values <0.004). For prior-24-hour recalls compared to previous-day recalls, and for prior-24-hour recalls in the afternoon and evening compared to previous-day recalls in the afternoon and evening, omission rates were better by one third, intrusion rates were better by one half, and total inaccuracy was better by one third. CONCLUSIONS: To enhance children's dietary recall accuracy, target periods and interview times that minimize the retention interval should be chosen.

Twenty-four hour dietary recalls by fourth-grade children were not influenced by observations of school meals.

OBJECTIVE: To investigate whether school-meal observations influenced children's 24-hour dietary recalls. STUDY DESIGN AND SETTING: Over three school years, 555 randomly selected fourth-grade children were interviewed to obtain a 24-hour dietary recall; before being interviewed, 374 children were observed eating two school meals (breakfast, lunch), and 181 children were not observed. Within observation-status groups (observed, unobserved), children were randomized within sex to one of six combinations from two target periods (prior 24 hours, previous day) crossed with three interview times (morning, afternoon, evening). RESULTS: For each of the five variables (interview length, meals/snacks, meal components, items, kilocalories), naïve and adjusted equivalence tests rejected that observation-status groups were different, indicating that school-meal observations did not influence children's 24-hour dietary recalls. There was a target-period effect on length (P<0.0001) (longer for prior-24-hour recalls), a school year effect on length (P=0.0002) (longer for third year), and a target period-interview time interaction on items (P=0.0110) and kilocalories (P=0.0047) (both smaller for previous-day recalls in the afternoon than prior-24-hour recalls in the afternoon and previous-day recalls in the evening), indicating that variables were sufficiently sensitive and psychometrically reliable. CONCLUSION: Conclusions about 24-hour dietary recalls by fourth-grade children observed eating school meals in validation studies are generalizable to 24-hour dietary recalls by comparable but unobserved children in nonvalidation studies.